Methods

Study Design and Setting

This was a retrospective observational study using de-identified complete national data from the annual American Medical Association (AMA) National Graduate Medical Education (GME) Census.

Study Population

The study population included all categorical residents without prior United States graduate medical education training who entered ACGME-accredited EM programs between academic years 2006–2007 and 2015–2016. The attrition group consisted of any resident at any level who left his or her program during a specific year.

Measurements

We calculated the attrition rate for any year using aggregated national data as the percentage of all residents who left their programs. To ensure anonymity the de-identified dataset included resident characteristics that were limited to gender, race/ethnicity, and medical school type (i.e., allopathic, osteopathic, and international). Per the census database, a primary status and reason for each resident departure was reported by the program director (PD). Attrition statuses included the following: 1) dismissal; 2) transfer to another EM program; 3) transfer to a non-EM program; 4) transfer unknown; and 5) withdrawn. Transfer "unknown" means whether it was unknown by the PD at the time of the report to the AMA National GME Census to what specialty the trainee transferred. Reasons for attrition included the following: 1) change in career plans; 2) health/family reasons; 3) military obligations; and 4) other/unknown.

There are two main ways to view resident attrition: There is attrition from the training program the resident initially enrolled in, and there is attrition from the specialty altogether. For several reasons, we chose the most inclusive definition by counting all attrition statuses, including attrition from one EM program to go to another EM program as well as attrition from the specialty altogether. First, we wanted to be consistent with prior work in other specialties so as to be able to compare our results.[10] Second, attrition from a program or a specialty results in the same negative consequences of morale, workload, and scheduling for the program and its remaining residents. Third, residents who leave one EM program to go to another EM program may highlight the unique systemic challenges he or she faced in that particular program, rather than challenges due to a poor specialty choice, which one presumes would result in attrition to another specialty. Since we were unable to parse out specific details of why each resident left his or her program based on the attrition status and reason reported by PDs, we aimed to provide the most inclusive definition of attrition to gain the most complete picture.

Outcomes

Our primary outcome was the annual national rate of EM resident attrition. Secondary outcomes included the main status and reason for attrition as well as resident characteristics associated with attrition.

Data Analysis

We analyzed data using SPSS for Windows v24.0 statistical software (SPSS, Inc., Chicago, Illinois). To assess for the presence of differences in attrition as well as the status and reason for attrition based upon resident characteristics (i.e., gender, race/ethnicity, medical school type), we employed chi-square analyses followed by the Marascuilo procedure where appropriate for the data.[11] To ensure differences in attrition by gender were not due to potentially changing numbers of women choosing to specialize in EM over time, we evaluated changes in the proportion of female residents using simple linear regression, with the proportion of female residents serving as the outcome variable and calendar year serving as the predictor. Comparisons of independent proportions were made using the z-test. Data are presented as counts, proportions, and 95% confidence intervals (CI) around proportions. All p-values were two-tailed; we accepted p<0.05 as statistically significant. This study was reviewed and determined to be exempt by the Maine Medical Center Institutional Review Board.

EM, emergency medicine; CI, confidence interval; df, degrees of freedom.*χ2=67.516; df=24; p<0.001. American Indian/Alaska Native, Native Hawaiian/Pacific Islander, Other, and Unknown were not included due to their small sample sizes.

References

Authors and Disclosures

Authors and Disclosures

*Tufts University School of Medicine, Department of Emergency Medicine, Medford, Massachusetts†Maine Medical Center, Department of Emergency Medicine, Portland, Maine‡Wake Forest School of Medicine, Department of Emergency Medicine, Winston-Salem, North Carolina§The University of Colorado School of Medicine, Department of Emergency Medicine, Aurora, Colorado¶The Ohio State University College of Medicine, Department of Emergency Medicine, Columbus, Ohio

Conflicts of Interest By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. This study was supported by funding from the Council of Emergency Medicine Residency Directors awarded in July 2017.